Entries Tagged as 'Am J Emerg Med'
The effect of an observation unit on the rate of ED admission and discharge for pyelonephritis.
Am J Emerg Med. 2010 Jul;28(6):682-8
Authors: Schrock JW, Reznikova S, Weller S
OBJECTIVES: We sought to determine if the opening of an adult emergency department (ED) observation unit (OU) would impact the rate of hospital admission and ED discharges for pyelonephritis. METHODS: A retrospective cohort study was performed with all adult patients from October 2003 through December 2006 in the ED meeting inclusion criteria for pyelonephritis. Clinical, demographic, and laboratory data were recorded. Primary outcomes were rates of admission, ED discharge, and return ED visits before and after the opening of our OU. We compared admission, discharge, and readmission rates using the chi(2) test. RESULTS: Nine hundred thirty charts were reviewed with 633 included for analysis. Urine cultures were performed on 420 subjects with 71% being positive. The percentage of patients admitted to a hospital inpatient unit from the ED decreased from 36% to 26% (relative risk [RR], 0.73; P = .01) after opening the OU. The percentage of patients discharged home from the ED decreased from 65% to 51% (RR, 0.76; P < .001). Among OU patients, 29% were admitted to the hospital for further inpatient care. Emergency department recidivism was unchanged by opening the OU (RR, 0.86; P = .68). CONCLUSIONS: The creation of an OU appears to influence admission decisions of ED physicians. We found that the creation of an OU significantly reduced hospital admissions for pyelonephritis but also significantly reduced ED discharges to home for pyelonephritis at our institution.
PMID: 20637383 [PubMed - indexed for MEDLINE]
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Ultrasound guidance for central venous catheter placement: results from the Central Line Emergency Access Registry Database.
Am J Emerg Med. 2010 Jun;28(5):561-7
Authors: Balls A, LoVecchio F, Kroeger A, Stapczynski JS, Mulrow M, Drachman D,
BACKGROUND: Ultrasound guidance of central venous catheter (CVC) insertion improves success rates and reduces complications and is recommended by several professional and regulatory organizations. METHODS: This is a prospective observational study using data extracted from the Central Line Emergency Access Registry database, a multicenter online registry of CVC insertions from medical centers throughout the United States. We compared success rates with ultrasound and with the anatomic-landmark technique. RESULTS: A total of 1250 CVC placement attempts by emergency medicine residents during the study period were selected from the Central Line Emergency Access Registry database. Because a few attempts (n = 28) were made to place lines in either the left or right supraclavicular locations, data on these attempts were eliminated from the analysis. A total of 1222 CVC attempts from 5 institutions were analyzed. Successful placement on the first attempt occurred in 1161 (86%) cases and varied according to anatomic location. Ultrasound guidance was used in 478 (41%) of the initial attempts. The remainder of placements were presumably placed using the anatomic-landmark technique based on visible surface and palpatory subcutaneous structures. Overall successful placement rate did not vary according to the use of ultrasound guidance, nor did it vary at different anatomic sites. However, ultrasound was found to be significant for reducing the total number of punctures per attempt (P < .02, t = 2.30). CONCLUSIONS: Our study did not observe improved success with the use of ultrasound for CVC cannulation on the first attempt, but we did observe a reduced number of total punctures per attempt.
PMID: 20579550 [PubMed - indexed for MEDLINE]
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Efficacy of tramadol vs meperidine in vasoocclusive sickle cell crisis.
Am J Emerg Med. 2010 May;28(4):445-9
Authors: Uzun B, Kekec Z, Gurkan E
Despite progress in management, patients with sickle cell disease who are experiencing acute painful episode are often incompletely treated. We compared meperidine and tramadol with respect to their effects on the hemodynamics and pain relief in patients with sickle cell disease who were admitted to the emergency department with painful crisis. A total of 68 patients with sickle cell disease were randomly assigned to receive either tramadol 1.5 mg/kg (n = 34) or meperidine 1 mg/kg (n = 34). Hemodynamic parameters were recorded at regular intervals after analgesic infusions. Pain intensity and relief were documented by visual analog and pain relief scale, respectively. Sedation level was defined according to Ramsay sedation scale. Both meperidine and tramadol administration resulted in a significant reduction in systolic and diastolic blood pressure after 2 hours (P < .05). Efficacy in pain relief between the analgesics was more rapid and better in the meperidine group, although the degree of relief were significantly improved compared to baseline levels in both groups (P < .05). Sedation was more commonly seen in the meperidine arm. None of the patients had experienced neurotoxicity. In summary, both agents had proven safe and effective for emergent use in patients with sickle cell disease. Avoiding meperidine injections as recommended with previous guidelines needs to be carefully reconsidered especially when low doses are mentioned.
PMID: 20466223 [PubMed - indexed for MEDLINE]
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Needle tip visualization during ultrasound-guided vascular access: short-axis vs long-axis approach.
Am J Emerg Med. 2010 Mar;28(3):343-7
Authors: Stone MB, Moon C, Sutijono D, Blaivas M
OBJECTIVES: Ultrasound guidance for central venous catheterization improves success rates and decreases complications when compared to the landmark technique. Prior research has demonstrated that arterial and/or posterior vein wall puncture still occurs despite real-time ultrasound guidance. The inability to maintain visualization of the needle tip may contribute to these complications. This study aims to identify whether long-axis or short-axis approaches to ultrasound-guided vascular access afford improved visibility of the needle tip. METHODS: A prospective trial was conducted at a level I trauma center with an emergency medicine residency. Medical students and residents placed needles into vascular access tissue phantoms using long-axis and short-axis approaches. Ultrasound images obtained at the time of vessel puncture were then reviewed. Primary outcome measures were visibility of the needle tip at the time of puncture and total time to successful puncture of the vessel. RESULTS: All subjects were able to successfully obtain simulated blood from the tissue phantom. Mean time to puncture was 14.8 seconds in the long-axis group and 12.4 seconds in the short-axis group (P = .48). Needle tip visibility at the time of vessel puncture was higher in the long-axis group (24/39, 62%) as opposed to the short-axis group (9/39, 23%) (P = .01). CONCLUSIONS: In a simulated vascular access model, the long-axis approach to ultrasound-guided vascular access was associated with improved visibility of the needle tip during vessel puncture. This approach may help decrease complications associated with ultrasound-guided central venous catheterization and should be prospectively evaluated in future studies.
PMID: 20223394 [PubMed - indexed for MEDLINE]
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Increased rate of central venous catheterization procedures in community EDs.
Am J Emerg Med. 2010 Feb;28(2):208-12
Authors: Glickman SW, Krubert C, Koppenhaver J, Glickman LT, Schulman KA, Cairns CB
OBJECTIVE: Central venous catheterization (CVC) is integral to the emergency department (ED) treatment of critically ill patients, such as those receiving early goal-directed therapy for severe sepsis. No previous studies have described the overall use of CVC in community EDs. The objective of this study was to estimate the overall frequency and temporal trends in CVC use in a sample of patients visiting community EDs. METHODS: This was a retrospective observational study of 2.97 million patient visits at 28 community EDs (range of annual visits, 10 837-110 136) from January 2004 to February 2008. Data were obtained from a community-based research consortium. Central venous catheterization procedures were aggregated at the hospital level for each study year. Trends in CVC use were evaluated using linear regression. RESULTS: Three thousand four hundred eighty-nine patient visits (0.12% of all ED patient visits) had a CVC procedure performed in the ED. The overall rate of CVC procedures per 1000 ED patient visits increased from 0.87 (95% confidence interval [CI(95%)], 0.80-0.95) in 2004 to 1.62 (CI(95%), 1.38-1.91) procedures in 2008 (P value for trend = .003). There was wide variability in the frequency of CVC procedures performed among EDs, ranging from a low of 0.27 (CI(95%), 0.18-0.42) to a high of 7.58 (CI(95%), 6.27-9.17) procedures per 1000 ED visits. The CVC procedure rates were lower in the 8 rural EDs (0.99 CVCs per 1000 ED patient visits [CI(95%), 0.91-1.07] compared with the 20 urban EDs (1.22 CVCs [CI(95%), 1.18-1.27]; P < .001). An increasing rate of CVC procedures during the study period was observed in urban EDs (0.84-1.94 CVCs per 1000 ED patient visits; P value for trend = .005) but not in rural EDs (1.1-0.93; P value for trend = .41) during the study period. CONCLUSION: The overall rate of CVC increased from 2004 to 2008. However, there was a wide variation among Eds, and the CVC rate was lower in rural compared with urban EDs. The increase in CVC use in urban EDs may reflect more intensive therapy in the management of ED patients with acute illness or injury. Future efforts are needed to optimize best practices for the use of CVC in community ED practices and to characterize factors responsible for urban rural differences in the rate of CVC procedures.
PMID: 20159392 [PubMed - indexed for MEDLINE]
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Patients with coronary disease fail observation status at higher rates than patients without coronary disease.
Am J Emerg Med. 2010 Jan;28(1):19-22
Authors: Madsen T, Bossart P, Bledsoe J, Bernhisel K, Cheng M, Mataoa T, Bartlett J, McKellar A, Rivas W, Quick N
BACKGROUND: Few studies have evaluated emergency department (ED) observation unit chest pain protocols for optimal patient characteristics and admission rates. At our 35 000-visits/y ED, we implemented a chest pain protocol for our observation unit that allowed emergency physicians to admit patients with known coronary artery disease (CAD). METHODS: We performed a retrospective chart review of all observation unit patients admitted under the chest pain protocol from April 1, 2006, to May 31, 2007. We compared the outcomes of patients who had a history of CAD with those who did not. RESULTS: Five hundred thirty-one patients were admitted to the observation unit under the chest pain protocol for the 14-month study period. Of these patients, 125 (23.5%) had a history of CAD. Patients with a history of CAD had a higher inpatient admission rate ( 24% vs 8.6%; P < .001), higher rate of a positive stress test or positive coronary computed tomographic scan (32.3% vs 6.9%; P < .001), a higher rate of cardiac catheterization (12% vs 5.9%; P = .02), and a higher rate of stent placement or coronary artery bypass graft (CABG) (7.2% vs 2.2%; P = .007). In multivariate analysis, patient history of CAD was an independent predictor of hospital admission (P = .005) and stent placement or CABG (P = .030). CONCLUSION: Patients with known CAD who were admitted to the ED observation unit failed observation status (ie, required hospitalization) and had higher rates of positive testing than those without CAD.
PMID: 20006196 [PubMed - indexed for MEDLINE]
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Randomized evaluation of octreotide vs prochlorperazine for ED treatment of migraine headache.
Am J Emerg Med. 2009 Feb;27(2):160-4
Authors: Miller MA, Levsky ME, Enslow W, Rosin A
Patients with headaches account for approximately 2% of all ED visits, with migraines being the most common defined primary headache syndrome. Our goals were to evaluate the efficacy of intravenous octreotide (OC) for the treatment of migraines, when compared to standard therapy with prochlorperazine. METHODS: The study was conducted as a double-blinded, randomized controlled trial. Each subject received either 100 microg of octreotide or 10 mg of prochlorperazine intravenously for a 2-minute period. RESULTS: Comparison of the change in median visual analog scale scores for 60 minutes demonstrated that octreotide was less effective at reducing pain (P = .03) and producing clinical success (P < .01). Restlessness consistent with akathisia was noted by 35% of the PC group and 8% of the OC group (P < .01). At 60 minutes, rescue medication was required by 48% of the patients in the OC group, whereas 10% of the PC group required such therapy (P < .01). All 44 patients were contacted for follow-up at 48 to 72 hours after enrollment. At that time, 10% of the prochlorperazine and 25% of the octreotide patients had experienced some headache recurrence (P = .1). CONCLUSION: Prochlorperazine was statistically superior to octreotide in clinical success rate and decrease in pain in migraine patients but caused more restlessness and sedation.
PMID: 19371522 [PubMed - indexed for MEDLINE]
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Validation of self-reported chronic obstructive pulmonary disease among patients in the ED.
Am J Emerg Med. 2009 Feb;27(2):191-6
Authors: Radeos MS, Cydulka RK, Rowe BH, Barr RG, Clark S, Camargo CA
BACKGROUND: To determine whether the self-reported diagnosis of adults who present to the emergency department (ED) with an acute exacerbation of either asthma or chronic obstructive pulmonary disease (COPD) is validated by medical record review. METHODS: This is cross-sectional study of 78 consecutive adults, 55 years and older, presenting to 3 EDs with symptoms suggestive of an exacerbation of asthma or COPD. We used current spirometric guidelines for a "spirometrically validated" diagnosis of COPD (eg, postbronchodilator forced expiratory volume in 1 second/forced ventilatory capacity <70%). Patients without office spirometry result were classified with COPD using clinical validation based on at least one of the following: primary care physician diagnosis of COPD, chronic bronchitis, or emphysema in the medical record or chest radiography, chest computed tomography, or arterial blood gas (ABG) diagnostic of COPD. RESULTS: Among 60 patients who self-reported diagnosis of COPD, 98% (95% confidence interval, 89-100) had clinically validated or spirometrically validated COPD. In addition, 83% (95% confidence interval, 59-96) of patients who reported either asthma only or no respiratory disease had clinically validated or spirometrically validated COPD. In no case was the chest radiograph or the ABG useful as a stand-alone test in establishing the diagnosis of COPD. CONCLUSIONS: Patients 55 years and older presenting to the ED with acute asthma or COPD, even those with clinical symptoms but no diagnosis of COPD, are likely to have COPD. Clinicians should maintain a high index of suspicion for COPD when older asthma patients deny COPD.
PMID: 19371527 [PubMed - indexed for MEDLINE]
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Splenic infarction: 10 years of experience.
Am J Emerg Med. 2009 Mar;27(3):262-5
Authors: Antopolsky M, Hiller N, Salameh S, Goldshtein B, Stalnikowicz R
OBJECTIVE: The aim of this study was to study the clinical presentation of splenic infarction. METHODS: A retrospective examination of files during a 10-year period was conducted. Only computed tomography-proven diagnoses of splenic infarction were included. Signs, symptoms, medical history, and results of investigation were recorded. RESULTS: We found 49 episodes of acute splenic infarction. Abdominal or left flank pain was the most common symptoms (80%), and left upper quadrant tenderness was the most common sign (35%). Splenic infarction was the presenting symptom of underlying disease in 16.6% of the patients. Based on the computed tomography results, ultrasound was diagnostic only in 18% of patients. There was no in-hospital mortality or serious complications. DISCUSSION: We present, to the best of our knowledge, the largest series of patients with splenic infarction diagnosed on clinical and radiological grounds. Awareness of the diagnostic possibility of splenic infarction in a patient with unexplained abdominal pain is important because it can be the presenting symptom of potentially fatal diseases.
PMID: 19328367 [PubMed - indexed for MEDLINE]
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Cost-effectiveness analysis of ED decision making in patients with non-high-risk heart failure.
Am J Emerg Med. 2009 Mar;27(3):293-302
Authors: Collins SP, Schauer DP, Gupta A, Brunner H, Storrow AB, Eckman MH
BACKGROUND: The ED disposition of patients with non-high-risk acute decompensated heart failure (ADHF) is challenging. To help address this problem, we investigated the cost-effectiveness of different ED disposition strategies. METHODS: We constructed a decision analytic model evaluating the cost-effectiveness of 3 possible ED ADHF disposition strategies in a 60-year-old man: (1) discharge home from the ED; (2) observation unit (OU) admission; (3) inpatient admission. Base case patients had no high-risk features. We used Medicare costs and the national physician fee schedule to capture ED, OU, and hospital costs, including costs of complications and death. All analyses were conducted using Decision Maker software (University of Medicine and Dentistry of New Jersey, Newark, NJ). RESULTS: Compared to ED discharge, OU admission had a reasonable marginal cost-effectiveness ratio ($44 249/quality adjusted life year), whereas hospital admission had an unacceptably high marginal cost-effectiveness ratio ($684 101/quality adjusted life year). Sensitivity analyses demonstrated that as the risk of early (within 5 days) and late (within 30 days) readmission exceeded 36% and 74%, respectively, in those discharged from the ED, OU admission became less costly and more effective than ED discharge. Similarly, an increase in relative risk of both early and late death in those discharged from the ED improves the marginal cost-effectiveness ratio of OU admission. Finally, as postdischarge event rates increase in those discharged from the OU, hospital admission became more cost-effective. CONCLUSION: Observation unit admission for patients with non-high-risk ADHF has a societally acceptable marginal cost-effectiveness ratio compared to ED discharge. However, as ED and OU discharge event rates increase, hospital admission becomes the more cost-effective strategy.
PMID: 19328373 [PubMed - indexed for MEDLINE]
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Fibrinolytic therapy in pulmonary embolism: an evidence-based treatment algorithm.
Am J Emerg Med. 2009 Jan;27(1):84-95
Authors: Fengler BT, Brady WJ
Patients presenting with pulmonary embolism (PE) have a wide spectrum of clinical severity. Although some patients may present with frank hemodynamic collapse and cardiac arrest, others may present with an asymptomatic PE that is discovered incidentally during workup of another condition. Fibrinolytic therapy is an option in the treatment of patients with PE due to its ability to rapidly dissolve thromboemboli clots. However, the use of fibrinolytics in the treatment of PE is a controversial topic that has left many practicing physicians confused on how to best treat these patients. A rational approach to deciding whether fibrinolytic therapy is indicated is based on an assessment of the benefit that each particular patient will derive from fibrinolytic therapy weighed against that patients risk for major bleeding and intracranial hemorrhage. There is a clear benefit/risk ratio for fibrinolytic therapy in patients with PE who present with cardiac arrest and in those who are hemodynamically unstable from a massive PE. With proper risk assessment, select patients with stable hemodynamics and right ventricular dysfunction may also benefit from fibrinolytic therapy. There is no benefit to fibrinolytic treatment in patients with stable hemodynamics and normal right ventricular function. This article sets out to review the literature on fibrinolytic therapy in the treatment of patients with PE and will propose an evidence based treatment algorithm.
PMID: 19041539 [PubMed - indexed for MEDLINE]
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Health care-associated pneumonia: identification and initial management in the ED.
Am J Emerg Med. 2008 Jul;26(6 Suppl):1-11
Authors: Abrahamian FM, Deblieux PM, Emerman CL, Kollef MH, Kupersmith E, Leeper KV, Paterson DL, Shorr AF
Traditionally, pneumonia is categorized by epidemiologic factors into community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP). Microbiologic studies have shown that the organisms which cause infections in HAP and VAP differ from CAP in epidemiology and resistance patterns. Patients with HAP or VAP are at higher risk for harboring resistant organisms. Other historical features that potentially place patients at a higher risk for being infected with resistant pathogens and organisms not commonly associated with CAP include history of recent admission to a health care facility, residence in a long-term care or nursing home facility, attendance at a dialysis clinic, history of recent intravenous antibiotic therapy, chemotherapy, and wound care. Because these “risk factors” have health care exposure as a common feature, patients presenting with pneumonia having these historical features have been more recently categorized as having health care-associated pneumonia (HCAP). This publication was prepared by the HCAP Working Group, which is comprised of nationally recognized experts in emergency medicine, infectious diseases, and pulmonary and critical care medicine. The aim of this article is to create awareness of the entity known as HCAP and to provide knowledge of its identification and initial management in the emergency department.
PMID: 18603170 [PubMed - indexed for MEDLINE]
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The prohibition on shocking apparent asystole: a history and critique of the argument.
Am J Emerg Med. 2008 Jun;26(5):618-22
Authors: Stewart JA
A recommendation against shocking asystole has been part of the American Heart Association’s Emergency Cardiovascular Care (ECC) Guidelines since 1992. The principal rationale offered then for the prohibition on shocking apparent asystole (PSAA) has since been refuted and has gradually been dropped, but the recommendation itself remains in the 2005 Guidelines. The PSAA now rests mainly on the lack of solid evidence of a survival benefit–a curious criterion given the lack of such evidence for most ECC treatment recommendations. “Occult” ventricular fibrillation and problems with distinguishing between fine ventricular fibrillation and asystole may lead to delays and omissions of potentially lifesaving shocks. No studies on the subject have been conducted since the PSAA first appeared. Removal of the PSAA from the ECC Guidelines is warranted to reopen research on this topic and support the goal of early defibrillation.
PMID: 18534295 [PubMed - indexed for MEDLINE]
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Severe intracranial and intraspinal subarachnoid hemorrhage after lumbar puncture: a rare case report.
Am J Emerg Med. 2008 Jun;26(5):633.e1-3
Authors: Liu WH, Lin JH, Lin JC, Ma HI
The lumbar puncture is considered as a safe routine procedure in widespread clinical use for nearly a century. To the best of our knowledge, intracranial and intraspinal subarachnoid hemorrhage has never been reported as a complication after a lumbar puncture.We presented a case of a 76-year-old woman who fell in a deep coma after a lumbar puncture with diffuse subarachnoid hemorrhage and acute obstructive hydrocephalus on computed tomographic scans. Magnetic resonance imaging studies of the whole spine showed the hematoma spread along the spinal cord upward to the intracranial subarachnoid space. Remarkably, an extravasation of contrast medium presented at the level of L1 through L2, which was subsequently evaluated using the spinal angiography. There was an ongoing bleeding at the terminus of L1 lumbar segmental artery that lay within the spinal cord. Then a transarterial embolization followed and the hemorrhage stopped immediately. This case reminds us that although lumbar puncture is safe and simple, severe potential complication, such as intracranial and intraspinal subarachnoid hematoma, could occur.
PMID: 18534309 [PubMed - indexed for MEDLINE]
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